Iraq Health Needs Assessment Working Paper by S2rT15

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									                              Primary Health Care

Iraq pledged to adopt the Primary Health Care (PHC) approach in 1978 but has always
had a centrally run, vertically administered health system based more on hospitals.

The PHC approach requires decentralized, decision-making. The MOH has been a very
hierarchical organization led by the Minister of Health and his three deputies. The 10
offices attached to the Minister or 3 offices of his first deputy have made many of the
decisions that should occur at the local level. A similar hierarchy exists in governorate
MOH offices. All the central directorates were represented in the DOH, but to a lesser
administrative scale.

PHC is provided at more than 1000 health centers and sub-centers providing preventive
and basic curative services and simple diagnostic procedures. They function from 8:00 –
14:00 hours and charge nominal fees. Services provided are supposed to include:

      MCH (antenatal, postnatal, neonatal care, growth monitoring for under-fives,
       control of diarrheal diseases, control of acute respiratory infections, immunization
       of mothers and children, dental care for mothers and children, and family
       planning
      Training of midwives, training of health staff and teachers,
      Participation in the PHC local council
      Health education activities,
      School health services, including dental care and eye care
      Monitoring of water quality and sanitation,
      Monitoring of food safety in restaurants, cafés and hotels,
      Epidemiological surveillance,
      Prevention of non-communicable diseases,
      Promotion of mental health,
      Vital statistics registration

Groups of PHCCs located in the same district are affiliated to of the country’s 115 PHC
sectors. The PHC section in the DOH leads the sectors. PHCCs are meant to refer to the
second level of care at MOH’s 100 district and general hospital. These provide
outpatient and inpatient care and diagnostic services. They function 24 hours a day and
charge nominal fees. The third level of care includes teaching hospitals, specialized
hospitals and specialized centers. These provide high-level diagnostic, curative and
rehabilitative services.

Other Health Service Providers

The Semi-Private sector includes public clinics operating at PHCCs in the afternoon.
They provide curative services and distribute drugs for patients with chronic diseases.
Their fees are higher than those charged in the public centers, but lower than the private
sector. The Private Sector includes private clinics, hospitals, day clinics, labs, imaging


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clinics, and pharmacies. All charge fees similar to a week’s average income. The private
sector also includes polyclinics manned by junior doctors. They charge fees averaging
10% of the private offices. The Military Medical Services has provided care to the
military their families free of user fees. It includes 31 hospitals with 1200 beds. They do
not have PHCCs, but rather dispensaries for outpatient services.

Traditional, unqualified healers include traditional birth attendants, bonesetters, herbal
medicine dispensers, parapsychologists and religious healers.

Manpower for the health sector includes doctors (graduates of medical colleges),
paramedical staff (graduates of the college of medical technology or of health institutes)
and nursing staff (graduates of nursing colleges, nursing institutes, nursing high schools,
or nursing primary schools). Other staff includes pharmacists, engineers, technicians,
statisticians, clerks, accountants, computer staff, and secretaries. Not all PHCCs are fully
staffed; many have left their jobs or even the country.

Most health facilities are the property of the MOH. When such buildings are not
available, the MOH rents buildings from the private owners.

Catchment areas and populations were not allocated for health centers. A new population
census is needed to identify, categorize and assess the adequacy of PHCCs. The reform
should include the restructuring of health facilities & their upgrading in terms of
premises, staff and equipment. A new system of registration, record keeping and patient
tracing for referrals will be needed. This should be accompanied by a countrywide
information campaign to orient the population to the new primary care system.

Moral of primary care health workers is quite low due to poor working conditions and
very low salaries. Many PHC of doctors have left primary care to work privately or in
other countries. The number of health workers at most PHCCs is too low, resulting in a
work overload and low quality. Outreach visits, health education and counseling
activities have virtually disappeared. The number of staff should be raised initially to one
__(Dr. Nada – one what?)____ per PHCC. IT should subsequently be raised to 1 per
20,000-population ratio. Also needed for the outreach services are easy transport and
overtime pay.

Providers at secondary level facilities are overloaded with cases that can be adequately
managed at the primary level. At the hospital level, we need competent feedback
mechanisms, to always refer the patient back to the PHCC after discharge from a
hospital.

The capacity of PHCCs was reduced by half compared to pre-war levels. Immunization
coverage was estimated by UNICEF to be 60-70%. Disease surveillance is currently
being implemented in sentinel sites, not routinely. It is anticipated that routine
surveillance will be reactivated soon.




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Dr. Nada – can you make some comparison of the theoretical staffing ratios in the table
to actual staffing levels?

Suggestions

Conduct detailed study human resources in the health system (numbers, qualifications,
job descriptions, job satisfaction and distribution), health facilities (types, duties,
services, distribution, premises, equipment, and cost recovery), client satisfaction and
utilization of the services provided. The PHC approach in the delivery of health services
should be adopted.

Table 1: Staffing Norms for PHCCs
Unit                                    Staff                               Staff/population
Curative                                General Practitioner                1/10,000
                                        Medical Assistant                   1/10,000
Dental                                  Dentist                             1/20,000
                                        Dental Assistant                    1/20,000
Pharmacy                                Pharmacist                          1/20,000
                                        Assistant Pharmacist                1/20,000
Lab                                     Technician                          1/20,000
X-Ray                                   Radiologists
Dressing                                One male and one female nurse
Special units (only in remote areas,    Emergency ward: nurse
6-8 beds)                               Labor room: nurse/midwife
Admin. /service                         Clerk, statistician, aide, driver
Preventive Unit                         Doctor for MCH care                 1/20,000
                                        CDD/ARI nurse, vaccinator,
                                        health audit, school health
                                        assistant, refractionist, record
                                        keeper


Table 2: Levels of Public Hospitals in Iraq
Hospital   Population        No.       of Wards                                 Staff
Level      Served            Beds
Rural:     20,000+,          20-50         1.Medical                            GPs from
Small      population                      2.Obstetrics                         PHCCs,
hospital   density    not                  3.Pediatrics                         nursing &
or ward    exceeding                       4.Basic surgical                     para-
in         5/sq.Km,                        5.Infectious                         medical
PHCC       radius of area                  6.Geriatrics and chronic
           40-60 KM
District   60,000-           60-150     1.Medical                               Specialists,
Hospital   150,000           (1/1000)   2.Obstetrics and gynecology             Visiting
           *one per          population 3.Pediatrics                            doctors &


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           district                      4.General surgery                     GPs,
           * patients are                5.Infectious
           referred from                 6.Geriatrics and chronic
           PHCCs and                     7.Triage
           private clinics               8.Rehabilitation
           within the area               9. Sub-specialties by visiting
                                         doctors
General    200,000-           1.75-1.85 All     specialties    and      sub-   Specialists
Hospital   400,000            per 1000 specialties, with intensive care        in major &
           *one or more       population units, forensic medicine &            sub-
           per                           occupational medicine                 specialties,
           governorate                                                         nursing &
           * patients are                                                      para-
           referred from                                                       medical
           PHCCs, private
           clinics, rural &
           district
           hospitals
Area       2,000,000-         1.75-1.85     All specialties and sub-           Specialists
Hospital   4,000,000          per 1000      specialties, with intensive care   in major &
           ** patients are    population    units, forensic medicine &         sub-
           referred from      for major     occupational medicine. Also rare   specialties,
           PHCCs, private     specialties   specialties: endocrinology,        as well as
           clinics, rural,    & 1.15-       neurosurgery, cancer surgery,      rare
           district &         1.25 for      cardio thoracic surgery,           specialties
           general            rare          faciomaxillary surgery, etc…       nursing &
           hospitals          specialties   May also function as a teaching    para-
                                            hospital.                          medical




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